Rice, maize and soya can be used as substitutes; all the others contain gluten.
Central chest pain which is worse on deep inspiration and relieved by sitting forward suggests acute pericarditis. Left inframammary pain suggests effort syndrome. A heavy meal and exposure to cold are well-known factors which precipitate or favor ischaemic cardiac pain.
Indications of a severe outcome include onset with brain-stem or cerebellar lesions, onset after the age of 40 and disease which is progressive from the onset
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